Cards cards 2 Flashcards
What does LGE actually mean on MRI?
- GAD washes out more slowly from areas of fibrosis or acute cell necrosis
- can predict recovery of function after revascularisation
- good to look for sarcoid
- see subendocardial sparing in myocarditis and NON ISCHAEMIC causes
- in amylodosis diffuse LGE from subendocardium
How many METs for ADLs?
5
What meds to stop pre exercise test?
beta blocker one day
digoxin one week
Sens and spec EST?
78% both
Aim to achieve workload in EST?
220/210 minus pt age
over 9-12 minutes exercise
satisfactory if get to 85%
Remember pathological ST segs are horizontal or downslopint
Upsloping ok
When to stop an EST>
Pt asks to
SEVERE chest pain, dizziness, or dyspnoea
Fall SBP more than 20
Rise in BP to Systolic over 300 or diastolic over 130
Ataxia
Remember that BP will normally go up with exercise, to about 235
ST depression more than 3mm ST elevation over 1mm in a non Q wave lead Frequent vent extrasystoles new VT New AF or SVT development of new BBB New heart block 2 or 3 Cardiac arrest!
What is the most specific ECG sign on EST for ischaemia
Inversion of U wave
How does dobutamine work as as stress agent? What about adenosine, dipyridamole, regadenoson?
Dob- increase myocardial oxygen demands and contractility
Others- induce regional hypoperfusion via coronary vasodilation
Cannot do an EST if?
MI within 30 days severe AS, symptomatic Uncontrolled arrhythmia decop heart failure acute PE aortic dissection
Interpretation limited if LBBB, LVH, WPW pattern, pacing- may choose exercise stress echo instead
Compare sens and spec of exercise ECG, PET stress, stress echo, nuclear spect
SENS: pet stress, nuclear spect, stress echo, stress ECG
SPEC: stress echo, PET stress, ECG and nuclear spect
Adenosine acts on
A2A receptors –>coronary artery vasodilation - if stenosis then there is relative flow heterogenicity introduced
can cause BRONCHOSPASM and AV block but short half life- avoid in uncontrolled asthma, heart block without pacemaker, sick sinus, critical AS
If get chest pain then not necessarily indicative of ischaemia
A1 receptors for the AV block side of things
Hold caffeine prior 12 hours
If want to look for flow heterogeneity use…
If want to assess LV function use…
vasodilators dobutamine (induce regional wall motion abn)
Regadenoson acts on
A2A receptors–>coronary vasodilation
Aminiphylline if the antidote
Avoid in heart block
easy as can just chuck in as a bolus
Dipyridamole acts on…
Indirectly vasodilates by INCREASING adenosine levels
Can bring on bronchospasm and rarely MI
In LBBB choose vasodilator stress echo why?
Because in exercise stress the conduction delay can cause a false positive abnormality
Dobutamine acts on…
beta1 beta2 alpha
When can dobutamine be useful?
COPD, asthma, critical aortic stenosis
CAN GIVE where adenosine not ok
Peak time of risk for contrast nephropathy?
3-5 days
How do you manage a pseudoaneurysm post angio?
Ultrasound guided compression or best supportive care
If cannot get haemostasis or femoral neuropathy–>surgical management
What should you do if you hear a 1/6-2/6 midsystolic murmur in asympromatic person?
Nothing else
Results of imaging unlikely to alter management
See a cardiac tumour that is probably secondary, most likely to come from…
Tumour that is most likely to met to heart is…
breast or lung
lymphoma and melanoma
If on ticagrelor, need to limit…
aspirin to 100mg or less per day (no benefit ticag if higher doses)
no more than 40mg atorvastatin (ticag increases dose)
Which side effect do they make a fuss about with ticagrelor?
Dyspnoea and ventricular pauses
this is adenosine mediated
What is the problem with tryin gto suck out clot during PCI?
Stroke risk double
What is the difference between femoral and radial approach for PCI?
Less bleeding with radial
Most sensitive test for aortic dissection
TOE!
CTA more practical though
Risk per year in stent thrombosis
0.8 across board
How long to defer non cardiac surgery post BMS
“At least 6 weeks and ideally 3 months”
How long to defer non cardiac surgery post DES?
12 months
have to stop DAP 5 days to allow bleeding compl to be ok
If you HAVE to stop, and deemed high risk, should do op in a PCI facility, monitor in HDU post op, and may consider bridging anticoagulation with heparin/tirofiban pr heparin/eptifibitide (GP2b3as)
?bridging anticoagulation
Guidelines say:
-low bleeding risk and mod-high risk in stent thrombosis then continue DAPT. Low risk bleed and low risk in stent thrombosis then just aspirin
- high risk bleeding and mod-high IST risk- stop DAP and cosider bridging therapy
- low risk IST then stop DAP
